1. Field of the Invention
The present invention relates generally to prescription drug benefits programs and more specifically relates to an improved dynamic claims adjudication system for adjudicating consumer purchases that are covered by such programs.
2. Related Art
Conventional systems for electronic claims adjudication by pharmacy benefits management (“PBM”) companies have been around for some time. A PBM is an administrator of prescription drug programs. PBMs are primarily responsible for adjudication and paying claims for covered prescription drugs that are purchased by consumers who are members of the prescription drug benefit program. Other typical PBM services include developing and maintaining the drug formulary (the list of drugs covered by the prescription drug benefits program and their associated tiers), contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers. Conventional PBM claim adjudication systems are typically employed when a member attempts to purchase a drug and the drug purchase is to be wholly or partially covered by a prescription drug benefits program. A prescription drug benefits program may be provided to the member through an employer health plan (e.g., ERISA plans, self insured plans, managed care plans, Taft-Hartley trust plans, etc.), or a privately purchased health plan, a government sponsored plan (e.g., Medicare, Medicaid or any other city, state or local or federal government plan) or directly from a PBM provider. In such a transaction, the originating entity (e.g., a pharmacy) electronically transmits a claim to the PBM through a switch company for adjudication of the claim. The PBM adjudicates the claim to validate, among other things, that the member has a valid prescription drug benefits program, that the prescribing doctor is valid, and that the drug is covered by the prescription drug benefits program. The PBM sends an electronic response back to the pharmacy that denies the transaction or approves the transaction and also identifies the co-pay amount.
At a high level, the overall process of adjudicating drug purchase claims covered by the variety of prescription drug benefits programs offered under various types of health care plans is similar such that the pharmacy electronically transmits a claim to the PBM, the claim is adjudicated, and an electronic response is sent back to the pharmacy. However, one of the significant challenges faced by PBMs during claim adjudication is that certain claims need to be adjudicated differently. For example, claims that are covered by a prescription drug benefits program provided under a Medicare Part D plan are adjudicated differently than claims that are covered by a prescription drug benefits program provided by a privately purchased health plan.
One significant drawback of conventional adjudication of prescription drug purchase claims is that they adjudicate claims in real time based on the formulary, which imposes rigid drug classifications that, for all members and all transactions, define the universe of available drugs and their associated tiers. The formulary also dictates the copays of the various drugs that are available and the respective adjudication rule set to be used to adjudicate a claim for a particular drug on a particular tier. Therefore, what is needed is a system and method that overcomes these significant problems found in the conventional systems as described above.